Thank you for considering this innovative program. If you are a physician practicing in Illinois and would like to apply for professional liability coverage, please complete the Medical Alliance Insurance Company Individual Professional Liability Application, which can be downloaded by clicking here. Please use the following checklist to ensure accuracy and completeness of your application. If you have any questions, please contact Ed Hozhauer at the address or phone number shown below.

1. Please complete each question. Don't leave any blanks. Mark "none" or "N/A" if it does not apply.
2. Explain any "yes" answers.
3. Attach a copy of your current Illinois Medical License.
4. Submit a copy of your current insurance declaration page.
5. Sign the Application and the Authorization & Consent form.